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Pediatric Pain :
Neuroaxial Blockade for Acute Pain Management
Intrathecal Administration
Epidural Administration
single
continuous
post-op management
“The Advantages to be gained
by the use of spinal anesthesia
have so far impressed me that I
am convinced it will occupy an
important place in the surgery
of children in the future.”
H. Tyrell-Grey
The Lancet 1909
Introduction
The following sessions illustrate the
advantages for using neuro-axial blockade
for pediatric pain management either
acutely or in combination with a general
anesthetic. The approaches delineated
remain designed for the general
practitioner as well as specialist. Even
though perhaps still evolving, these
techniques have and continue to benefit
many.
CASE
A three month of age boy is to have a
right inguinal hernia repaired. Upon review
he has had respiratory distress syndrome.
Wght: 3 kg
Hct: 30%
Preoperative Evaluation
Emergency? No
Why is the Surgery being performed?
PREOPERATIVE EVALUATION:
Problems History & Physical Laboratory Tests
1. RDS litany of basic knowledge CBC
2. Hyaline Membrane Ds Electrolytes
2. Prematurity Coags
3. Airway CXR (ABG, FEV1/FVC, F-V loop)
5. Full Stomach
ANY ISSUES TO BE ADDRESSED PRIOR TO ENTERING THE O.R.
Choice of Anesthesia
General Anesthesia
Regional Anesthesia
Peripheral Nerve Block
IV Regional
MAC
Local
Techniques for General
Anesthesia
4 Concerns to Guide the Plan:
Airway/ Full Stomach/ Volume Status/ Medical Problems
Is Regional an Option?
Rapid Sequence
Modified Rapid Sequence
Concerns How Medications
1. Airway 1. IV-IM 1. Administration sequence
2. Full Stomach 2. Inhalational 2. Including NMB Agent
3. Volume Status 3. Awake Fiber Optic 3. Analgesic Component
4. Medical Problems 4. Local Trach
Intrathecal Administration
I keep six honest serving men
(They taught me all I knew);
Their names are What and Why and When
And How and Who.
Rudyard Kipling 1865-1936
--The Just-So Stories (1902). The Elephant’s Child
What Efficient: What Needed
Why Physiology, Safety & Efficacy
When Patient Centered, Timely, Equitable
How Treatment
Who Background Demographics Introduction
Where Anatomy
What?
Anatomy : Intrathecal Space
Why?
The spinal cord anatomy
of the infant differs
from the adult, since
the cord terminates at
L3 in the infant not L2
as in the adult.
When?
For high risk infants less than 1 year of age. These
include infants with certain congenital anomalies, a history
of prematurity, or a history of neonatal respiratory
distress syndrome thereby increasing the risk for general
anesthesia.
How?
Technique: 1. Suggest premedication with atropine only
2. ASA monitors placed while infant remains fully awake in the OR
3. While receiving supplemental 02 with chin extended, the infant is placed into position
4. Prepare the lumber area with iodine solution
5. Identify the lowest palpable interspace below L3
6. Use 1% procaine for the skin weal analgesic
7. Draw 0.2 cc of 1% tetracaine in a TB syringe and add 0.2 cc of 10% dextrose for a
hyperbaric solution. By adding 0.02 cc of epi 1:1000 the effect may increase upwards to 100
minutes
8. Have available a variety of 22 or 25 gauge pediatric Quincke or Whitacre type spinal needles
9. After obtaining free flow of CSF from all planes of needle rotation, do not aspirate
10. Inject the hyperbaric solution plus 0.4cc more than needed to compensate for dead space.
11. Leave the needle in place for about 5 seconds to prevent back tracking of the solution from
the CSF, thus avoiding an incomplete or failed block.
12. Place the infant supine, while observing for the onset of lower extremity flaccidity, usually
within 2 minutes.
13. Maintain strict supine positioning until the block establishing the block, without leg elevation.
Such prevents potential migration of the block and a total spinal
Infant Spinal Anesthesia
1……………………….add Tb syringe
2…………………...add spinal needle
3……………………...add medication
Infant Spinal Anesthesia
4...use local
Infant Spinal Anesthesia
5………...…………..attach syringe firmly
6………………………………...do not aspirate
7….it is ok to inject into bloody CSF
Infant Spinal Anesthesia
8…...load syringe sterile and
have surgeon inject it
9…….if spinal begins to wear
off, repeat the dose
Infant Spinal Anesthesia
10…...start IV in anesthetized ankle
Infant Spinal Anesthesia
11…..note the placement of the drapes
Infant Spinal Anesthesia
close up
Infant Spinal Anesthesia
close up
Who?
High risk infants who had been born prematurely or were treated for
neonatal respiratory distress
Infants with congenital anomalies such as laryngomalacia, macroglossia,
or microagnathia
Most commonly the surgical indication is bilateral inguinal hernia repair,
but other surgery below the umbilicus is also considered:
colostomy for imperforated anus
recctal biopsy
closed reduction of hip dislocation
circumcision
correction of club foot
etc.
High Risk Infants Who Had Been
Born Prematurely
Consider Surgery Below the Umbilicus
Where?
Lowest palpable interspace below L3
Anatomy
Pitfalls
Dose: 1 mg for those infants < 1 year of age
then 0.25 mg/kg
mean duration of 84 minutes
with epi mean increased to 109 minutes
Alternates: 0.5% bupivicaine or 2.5% lidocaine
Results
group infants proceedures attempt attempt unsuccessful spinals requiring supplementation
# # 1st 2nd # #
high risk 36 36 31 5 0 6
anomaly 8 11 10 1 0 3
term 34 34 22 4 8 5
totals 78 81 63 10 8 14
Safety
Most Difficulty Lies in Positioning an Awake Wiggling Infant
The CSF Flow Must Remain Continuos As the Needle Rotates
Bloody Taps Occur More Often If Not Midline in Approach
With a Bloody Tap More Difficulty Arises in Locating the CSF
BP and Bradycardia Less Likely With Infants Than With Adults
The CSF Flow Must Remain
Continuous as the Needle Rotates
References
Abajian JC, Mellish PWP, Browne AD, Perkins FM, Lambert DW,
Mazuzan JE. Spinal Anesthesia for Surgery in Children and
Infant. Anesth Anal 1984; 63:359-62.
Gregory, GA and Steward, DJ. Life Threatening Perioperative
Apnea in the Ex-preemie. Anesthesiology 59:495-498, 1983.
Steward, DJ. Preterm Infants are More Prone to Complications
Following Minor Surgery than are Term Infants.
Anesthesiology 56:304-306, 1982.
PEDIATRIC PAIN
Epidural Administration
Kiddy Caudals
Epidural Administration
I keep six honest serving men
(They taught me all I knew);
Their names are What and Why and When
And How and Who.
Rudyard Kipling 1865-1936
--The Just-So Stories (1902). The Elephant’s Child
What Efficient: What Needed
Why Physiology, Safety & Efficacy
When Patient Centered, Timely, Equitable
How Treatment
Who Background Demographics Introduction
Where Anatomy
Single Administration
What?
1
With very little equipment
which includes a skin prep,
needle of choice, and
3 desired local anesthetic:
1………………...………...alcohol pad
5 4 2…….povidone idoine solution
2
3……….formal prep and drape
4……………..appropriate needle
5…..desired local anesthetic
single shot caudals provide
excellent analgesia
Why?
Caudals provide effective
adjunctive operative analgesia
lasting upwards of 4 to 6 hours
post-surgically in pediatric
patients. Moreover, these
techniques are relatively safe and
easy to perform.
When?
after induction of general anesthesia but before the
onset of surgical incision.
-the time required for placement translates into time regained post
operatively secondary to earlier anesthetic emergence
-patients commonly remain pain free for several hours post.
-greatly reduces the risk of laryngospasm due to surgical stimulation
especially during perineal procedures obviating the need for intubation
and the possibility of post-operative croup
How?
1. Properly position the patient
2. After the skin preparation, use the hypodermic
needle of choice at a 60 degree angle to the skin
until the sacrococygeal membrane is peirced.
3. Note a distintive ‘pop’ upon entering the sacral canal
4. Then further advance the hypodermic another 2mm
parallel the plane of the spinal axis.
5. Gently aspirate to confirm neither an intravascular
nor an intrathecal injection of local anesthetic.
6. Introduce the agent into the caudal epidural space
How to Position?
How to Proceed?
1. After the skin preparation,
use the hypodermic needle
of choice at a 60 degree
angle to the skin with the
bevel down until the
sacrococygeal membrane is
peirced.
2. Note a distintive ‘pop’ upon
entering the sacral canal
3. Then further advance the
hypodermic another 2mm
parallel the plane of the
spinal axis.
Caudal Epidural
1……….. enter membrane at 30 to 40 degrees
2…………………………..flatten toward the rectum
3…………………….advance about 1/4 to 1/2 inch
4……slip catheter off the needle into space
Caudal Epidural
5…………………….do not inject air
6…………………..aspirate catheter
Caudal Epidural
18 gauge cathalon
arrow caudal/epidural kit
Caudal Epidural
suitable dressing
tape up the side to allow for bovie pad
Who?
children having surgical procedures below the umbilicus:
circumcisions
orchidopexy
inguinal hernia repair
hydrocelectomy
rectal dilation
lower extremity orthopedic procedures
Where
Through the caudal space
Pediatric Acute Pain
Management Post-Operatively:
Continuous Epidural Infusions
Cardiothoracic Surgery
At our institution epidural remains the standard of care. So
much so that parents must specifically state refusal for this
preferred method of intra-operative and postoperative
analgesia not to be provided.
David A. Rosen, MD
Epidural
Dr. Chris Abajian pioneered spinal anesthesia for infants at
the University of Vermont and maintains the largest
database in the world on outcomes associated with this
technique
Chris Abajian, MD
Epidural
18 guage cathalon
arrow caudal/epidural kit
Caudal
22 gauge jelco catheter
inserted through the
sacrococygeal ligament
with a 24-gauge styleted
catheter threaded 1-3 cm
into the caudal space
usually.
arrow caudal/epidural kit
Epidural
suitable dressing
tape up the side to allow for bovie pad
Caudal
suitable bio-occlusive dressing applied
with a drape below and above the
insertion site providing a sterile
barrier resisting contamination from
urine and feces. Tape the catheter
connector to a tongue blade to add
1-2, 4-way stopcocks for medication
infusions
tape up the side to allow for bovie pad
Caudal Medications
Morphine
Hydromorphone
Clonidine
Local Anesthetics
lidocaine
bupivacaine
ropivacaine
Caudal Medications
Morphine
BOLUS INFUSION RATE SIDE EFFECTS
0.04 mg/kg 0.075 mg/kg 0.125 mcg/kg/min
somulence
>14 kg 10cc PFNS >14 kg 10cc PFNS 1 cc/hr nausea
<14 kg 5cc PFNS <14 kg 5cc PFNS 0.5 cc/hr vomiting
pruritis
< 1kg 3cc PFNS < 1kg 3cc PFNS 0.025 mcg/kg/min
*epidurally administered opiods require a minimum
of 8 hours of continuous pulse oximetry
Caudal Caveats
Morphine
If only using morphine throughout the case after the bolus of 0.04
mcg/kg infuse at 0.125 mcg/kg/min, then stop near the end to
facilitate extubation. Restart the infusion upon the child’s
awakening if placed in the caudal region as noted already. Or if the
catheter lies in the thoracic segments, for Down’s children or
premature infants begin at half the rate 0.0625 mcg/kg/min.
Should side effects (somulence without discomfort) arise
decrease the infusion by 0.025 increments.
For those individuals requiring continued ventilatory support
simply maintain the above maximum infusion.
Typically the epidural infuse for 2-3 days post-op thought upto
even 5 days are not uncommon
Caudal Medications
Hydromorphone
BOLUS INFUSION POST OP ADJUSTMENTS SIDE EFFECTS
0.5-1.0* 0.1-3.5* 0.1 and 0.5 increments* akin to morphine,
and more lipophilic
thus the catheter
tip lies in proximity
to the desired
dermatomal area.
*mcg/kg/hr
2xwghtx24 = mg added in PFNS for total of 48cc
Caudal Medications
Clonidine
BOLUS INFUSION POST OP ADJUSTMENTS SIDE EFFECTS
0.5-1.0* 0.1-5* 0.1 and 0.5 increments* profound analgesia
sedation
hypotension**
bradycardia**
*mcg/kg/hr
**ideal for coarctation patients
PF Clonidine comes as 100 or 500 mcg/cc
reduce the concentration by tenfold to 10 or 50 mcg/cc
Caudal Medications
Local Anesthetics: Bolus
LOCAL TEST DOSE LOADING DOSE
lidocaine (L) 0.1cc/kg 1-1.5%L epi 1:200k 1-1.5% L bolus to desired level
bupivacaine (B) 0.1cc/kg 0.25%B epi 1:200k 0.25% B 0.056 cc/kg/seg
ropivacaine (R)
Caudal Medications
Local Anesthetics: Maintanence
LOCAL INFUSION SIDE EFFECTS
lidocaine (L) 0.75% L @10-20mcg/kg/hr* somulence
bupivacaine (B) 0.1-0.125%** B @0.25mg/kg/hr hand tingling
extra-dermatomal numbness
ropivacaine (R) 0.1% R @ 10-20mcg/kg/hr pain with adequate sympathectomy
*lidocaine level obtained 12hr post op then daily while the infusion continues
**0.125% B used for children reaching tanner stage 4
Side Effects
Nalbuphene 0.025 mg/kg q 2hr prn nausea, vomiting, pruritis
should vomiting persist decrease the narcotic infusion
failing two trials of nubain, ondensatron
0.15 mg/kg up to 4mg iv q 4hr prn nausea,
vomiting, pruritis
prophylactic low dose propofol infusion starting at
1 titrating upto 10 mcg/kg/min might be considered
if these measures prove ineffective consider
metaclopramide 0.1mg/kg or dexamethasone 0.5mg/kg
vomiting more commonly in children > 3 years
facial itching noted more often in non-infants
respiratory depression rarely occurs with adherence to the dosage schedule
Complications
16 years of experience & over 5000 cases:
Problems Incidence
Insertional bleeding 5%
Catheter bleeding <1%
Intrathecal migration .05%
Catheter Shearing once only (no sequalae)
Durocutaneous fistula 0
Cauda-equina syndrome once only*
Meningitis twice**
* resolved spontaneously after 1 week
**developed weeks later following catheter removal
and no evidence relating to the epidural
Caveats
select those with optimal anatomy,
remain reluctant for those
without a base despite a caudal
dimple in such circumstances
consider a low lumbar approach
instead.
remember the ‘circle of errors’
place the non-dominant hand
across the sacral region dorsally
palpating for an inadvertent
subcutaneous injection by noting a
“bulge” midline.
Epidural
X-ray showing wrong catheter placement
Epidural
X-ray showing correct catheter placement
References
Abajian JC, Mellish PWP, Browne AD, Perkins FM, Lambert DW,
Mazuzan JE. Spinal Anesthesia for Surgery in Children and
Infant. Anesth Anal 1984; 63:359-62.
Broadman, Lynn M. Regional Anesthesia in Children. West
Virginia University, 1994.
Gregory, GA and Steward, DJ. Life Threatening Perioperative
Apnea in the Ex-preemie. Anesthesiology 59:495-498, 1983.
Rosen, A. David. Continuous Caudal Morphine Postoperatively.
January 26th, 2004.
Steward, DJ. Preterm Infants are More Prone to Complications
Following Minor Surgery than are Term Infants.
Anesthesiology 56:304-306, 1982.
Questions
T or F 1. In the infant the spinal cord terminates at L2 as in the adult.
T or F 2. Infants with a history of prematurity are excellent candidates
for pediatric spinals especially for surgery above the umbilicus.
T or F 3. As with most local anesthetic administration one should aspirate
prior to injection for the infant spinal.
T or F 3. Should bloody CSF appear one should immediately abandon the
pediatric spinal.
T or F 4. BP and bradycardia are less likely with infants than with adults.
Questions
T or F 1. In the infant the spinal cord terminates at L2 as in the adult.
T or F 2. Infants with a history of prematurity are excellent candidates
for pediatric spinals especially for surgery above the umbilicus.
T or F 3. As with most local anesthetic administration one should aspirate
prior to injection for the infant spinal.
T or F 3. Should bloody CSF appear one should immediately abandon the
pediatric spinal.
T or F 4. BP and bradycardia are less likely with infants than with adults.
Questions
T or F 5. Single administration caudals provide excellent analgesia.
T or F 6. “Kiddie Caudals” reduce the risk of laryngospasm due to surgical
stimulation.
T or F 7. The bevel of the hypodermic needle used for injection should be
pointing upwards as with placement of a peripheral intravenous.
T or F 8. As with most local anesthetics one should aspirate the epidurally
placed catheter prior to injection.
Questions
T or F 5. Single administration caudals provide excellent analgesia.
T or F 6. “Kiddie Caudals” reduce the risk of laryngospasm due to surgical
stimulation.
T or F 7. The bevel of the hypodermic needle used for injection should be
pointing upwards as with placement of a peripheral intravenous.
T or F 8. As with most local anesthetics one should aspirate the epidurally
placed catheter prior to injection.
Questions
T or F 9. Post-op pain relief requires an institutional commitment.
T or F 10. Any dressing will suffice for protection of the epidural catheter
insertion site from urine and fecal contamination.
T or F 11. Epidurally administered opiods require a minimum of 8 hours of
continuous pulse oximetry.
T or F 12. In general once the infusion rates are set for post-op epidurally
administered analgesics no further adjustments are required.
T or F 13. Careful titration to side effects and adequacy of post-op
analgesia is required for optimum results using epidurally given
medication.
Questions
T or F 9. Post-op pain relief requires an institutional commitment.
T or F 10. Any dressing will suffice for protection of the epidural catheter
insertion site from urine and fecal contamination.
T or F 11. Epidurally administered opiods require a minimum of 8 hours of
continuous pulse oximetry.
T or F 12. In general once the infusion rates are set for post-op epidurally
administered analgesics no further adjustments are required.
T or F 13. Careful titration to side effects and adequacy of post-op
analgesia is required for optimum results using epidurally given
medication.
